Other than reading about the occasional Kegel, many of us don’t spend much time thinking about our pelvic health, but we really should. You probably have questions you didn’t even realize you had. How common is pelvic pain? What’s the difference between “squirting” and just peeing a little? What can be done to rehab your pelvic floor after giving birth? Dr. Susie Gronski, physical therapist and certified pelvic rehabilitation practitioner answers all your burning questions.
Gronski isn’t an M.D. or gynecologist — she describes herself as a “physiotherapist for your privates,” training both women and men on how to be their own expert in treating whatever’s going on “down there.”
SheKnows: What don’t you do?
Susie Gronski: If you’ve got something more than muscle-based pain like smelly ejaculate, blood in your urine, weird lumps and bumps that just popped outta nowhere, fever or chills, go see an M.D. They’re the guys who do all the blood tests and scans to make sure nothing more serious is going on.
SK: What can you tell us about “squirting”?
SG: First, the name is misleading — it isn’t [an] über amount, so it isn’t super-wet like we see in porn. Authentic female ejaculate is a mixture of diluted urine and prostate-like fluid. It is created by a tiny little gland next to your urethra… when fluid comes out of the vagina during intercourse.
SK: How can you tell if its urine or prostate fluid?
SG: Other than checking the amount, you can do a smell test. If it smells like pee, it is pee. And a third option —that I don’t advise unless you check with you doc first — is to test with AZO urine strips.
SK: Do you think this recent obsession with “squirting” is in anyway tied to the porn industry? Has anyone contacted you asking about it?
SG: I have only had one woman ask about it virtually, but I believe that is because some people think that a large amount of fluid is normal. I think I would have more questions if people were more comfortable asking these types of questions.
SK: I have heard you mention coital incontinence before. I know incontinence means unintentional urinating or defecating. From what we discussed, coital incontinence is often mistaken for female ejaculate. How are they different and what is it?
SG: It is likely coital incontinence if it is a large amount. There are two kinds of coital incontinence: leaking during orgasm and leaking during penetration. When it happens during orgasm, it’s associated with overactive bladder. In other words, the bladder is contracting during orgasm, which leads to incontinence.
SK: Other than coital incontinence, what are signs that you could be having pelvic health issues?
SG: If you have any pain in the butt, hip or abdomen, you need to need to check on the state of your pelvis. Other surprising signs include painful periods, frequent peeing and constipation.
SK: Oh wow, I thought a lot of those issues were common.
SG: Common yes, normal no. And also, if you have persistent genital arousal syndrome.
SK: How common is pelvic pain?
Pelvic pain affects 1 in 7 women. Up to 20 percent of women experience pelvic pain at some point in their lives. You can treat this and other issues with pelvic floor therapy.
SK: What is pelvic floor therapy?
SG: In a nutshell, pelvic floor therapy helps with issues such as incontinence, constipation, pain with intercourse, pre- and postnatal care, post-surgical scarring and so much more.
SK: What are some other signs that someone needs pelvic floor therapy?
SG: Dyspareunia, which is pain during/after intercourse; vulvar or labial pain; painful periods; abdominal pain; tailbone pain; pain with sitting; groin pain; frequent urinary tract infections; pain during bowel movements or constipation. Common yes, normal no. And also pain or difficulty with orgasm/persistent genital arousal disorder… PGAD.
SK: What is PGAD?
SG: It’s pretty much hypersexuality without sexual intention (with or without orgasm). A lot of women who have it experience multiple unstimulated orgasms, and they’re painful.
SK: Oh, that sounds rough. What happens when you don’t orgasm?
SG: Lack of orgasm means the blood flow doesn’t get the chance to return, and if the blood flow does not return you are not getting rid of toxins.
SK: Are there any other benefits from orgasms?
SG: Yes! They release feel-good hormones, help with sleep, fight congestion, helps with memory and cognitive function, improves relationships and helps with confidence.
SK: How common is PGAD?
SG: We aren’t really sure yet. It’s still a developing area of research in the medical community. I’m hoping we get to learn more soon.
SK: How much of that do you think is because some women don’t talk sex?
SG: Good question. In order to do the research, you have to have test subjects. And in order to have subjects, we have to have a sample of women who are comfortable discussing these topics.
We don’t know exact rates, but I am fairly certain it is underreported — culture and sometimes religious beliefs influence women’s perspective of speaking on these topics.
SK: What causes urinary incontinence?
SG: A weak or overly tight pelvic floor. Many factors like birthing children, activities and menopausal stage.
SK: So, does age directly influence coital incontinence and/or urinary incontinence?
SG: Not really. It’s more that your muscle integrity changes when your estrogen levels drop. The drop in estrogen causes thin, weak pelvic floor muscles. Thinner muscles mean less control. However, you are at a substantially higher risk for coital incontinence if you have incontinence with other daily activities such as running, sneezing or laughing.
SK: Since estrogen changes are hormonal, what can be done to combat menopause-related issues?
SG: Exercise is the No. 1 way to treat a lot of these issues. Also, stress management helps a lot and hormone replacement therapy can be used for more urgent cases.
SK: So many of these issues seem so common!
SG: As I said before, these things are common, but not normal. Vaginal deliveries stretch not just the vagina but the bladder and the urethra. Everything in your body has changed and it is important to rehab theses areas. You would go to rehab if you were in an accident that limited your mobility, so why not get rehab postpartum, you know?
SK: Speaking of hormone therapy, how can we keep these issues in mind when working with transgender individuals? Does an increase in gender-affirming surgeries relate to these topics?
Yes! Definitely! After gender-affirming surgery it is particularly important to learning how to reconnect with your areas.
You will have to rehabilitate have those muscles, and those of us in my profession have the ability to teach them how to relearn and be comfortable with their bodies. I believe it is important for health care providers to address the needs of all people. I am doing what I can to help that population as best as possible.
A version of this article was originally published in January 2017.